Grant Partners

Community Health Connections will conduct intensive street and shelter outreach to individuals who are homeless, providing eligibility determinations and application assistance.  They will hold “office hours” at local organizations to answer questions regarding programs, eligibility requirements, and sources of care in the community.  A “Community Collaborations” group consisting of health and human services organizations will be convened, serving the region’s homeless, to share information about the Affordable Care Act.  

Community Action Committee of Cape Cod & Islands will continue individualized “Access to Care – Navigating the Massachusetts Health Care System” educational sessions for consumers, and design a training guide identifying MassHealth mailings and navigating the complex health care system.  They will conduct a series of outreach events to educate the public on changes through the Affordable Care Act.  

In their project titled “Best Opportunities for Improving Massachusetts Health within Budget Constraints,” the research team will use published cost effectiveness research and Massachusetts-specific data on current health care use to identify opportunities to reduce the use of overused low-value care and increase the use of underused high-value care.  Their simulation model will allow health care leaders to estimate total cost savings and health gains that could be achieved by reallocating resources from inefficient to efficient interventions.   

The Joint Committee for Children’s Health Care in Everett will provide application assistance and referral support, and conduct a multimedia publicity campaign to reach consumers about the Affordable Care Act.  Additional education will be provided through a multilingual helpline, website, and newsletter.  A series of educational sessions will be conducted at local community organizations on navigating the health system and using the Health Information Exchange.  

Through its Health Access Campaign, the Massachusetts Immigrant Refugee & Advocacy Coalition will advocate for all immigrants to maintain current coverage or obtain benefits under the Affordable Care Act.  It will translate and share information on health coverage options available through the federal law to educate members, policymakers, and community-based organizations that serve immigrant stakeholders.  

Hilltown Community Health Centers will assist with applications and annual eligibility reviews and connect patients with primary care providers.  They will provide monthly public education sessions on health coverage options for consumers, and adapt their electronic medical record to establish a referral system across departments.  Educational materials will be developed on the changes in the health insurance marketplace.  Finally, they will work with small businesses in the community that may be eligible for health care tax credits through the marketplace. 

The research team will use the APCD in their project titled “Understanding High-Cost Patients in Massachusetts” to provide in-depth analysis of the small percentage of patients who consume a disproportionately large share of health care spending in the state. By gaining a more detailed understanding of high-cost patients—their diagnoses, co-morbidities, demographic factors, and providers—the researchers hope to help inform the development and targeting of potential cost containment policies, practices, and payment models for Massachusetts.

Boston Center for Independent Living will continue to co-lead the Disability Advocates Advancing our Healthcare Rights (DAAHR) Coalition with the Disability Policy Consortium.  The organization will educate policymakers and legislative leaders, maintain and strengthen DAAHR, organize the disability community, develop organizational technical expertise, and provide policy analysis and input to the field, particularly related to the Duals Demonstration Project, known as One Care.

Community Health Programs will conduct a multi-pronged outreach effort throughout Berkshire County to educate consumers on affordable insurance options utilizing its mobile medical van.  They will conduct workshops for local community organizations to reach self-employed individuals and businesses.  A key focus will be on assisting individuals with the tax filing process, as the Modified Adjusted Gross Income is utilized for determining eligibility.  Finally, a campaign will be developed to educate individuals about appropriate use of the emergency room and primary care.  

Brockton Neighborhood Health Center will enroll consumers in coverage and assist with renewal applications, and provide education on the Affordable Care Act.  Community leaders from religious, cultural, and human service organizations will be convened and educated on health insurance information and available resources.

Community Health Center of Franklin County will provide a continuum of eligibility, enrollment and review services, resource referrals to primary care, and case management.  They will educate consumers on how to navigate health coverage and care systems through computer access, including the Health Information Exchange.  Educational materials will be developed for patients to take a more active role in their health coverage and care.  

Healthy Lives:  Brookline Community Mental Health Center will serve 200 low-income adults living in Brookline or Boston who present with serious mental illness (schizophrenia, bipolar disorder, major depression, severe anxiety, or PTSD) and at least two chronic medical conditions (including diabetes, cardiovascular disease, or COPD).  The health center will engage patients in their care, help them coordinate the services they receive, provide wellness interventions, offer disease management programs, home visits, and individual and group counseling. The intent of the project is to help patients move from passive recipients to active participants in their health care and by doing so, reduce cost and improve quality.

Steppingstone, Inc. will partner with Stanley Street Treatment and Resources (SSTAR) to create a new program called MyCare, an effort to promote a more pro-active approach to health care for those in Steppingstone’s residential recovery programs. The target population for MyCare is persons in early recovery from chronic substance abuse and mental health disorders.  Over 70% of this population has recent histories of homelessness and more than 70% have chronic conditions, in addition to their substance abuse or mental health disorders. The project will begin with residents of its Fall River women’s program in year one and will incorporate the Fall River men’s program in the second year, and its Stone Residence for chronically homeless individuals in the third year. The program projects to serve 465 clients over the three years with one-on-one assistance and intervention. 

In their project “Analysis of the Massachusetts All-Payer Claims Database to Describe the Epidemiology of Readmissions,” the research team will use the Massachusetts All-Payer Claims Database (APCD) to better understand patterns of hospital readmissions in Massachusetts. Most research on readmissions has been conducted using Medicare data or on data sets that describe only inpatient hospital encounters. By using the APCD, this research will shed new light on the diagnoses and patterns of care associated with readmissions in Massachusetts for all populations. This analysis could help providers develop and focus work around preventing avoidable readmissions.

Fishing Partnership Health Plan will educate households on the Affordable Care Act, targeting “family health brokers” and community leaders to be navigators in providing frontline education and enrollment assistance.  Seminars and trainings will be offered at shore side processing plants, industry meetings, occupational safety training seminars, and settlement houses, complete with a training curriculum for all navigators.  The “Do You Love a Fisherman?” campaign will be launched with marketing materials, services, and incentives targeting spouses and family members.